Pharmacy Services

medical rxCenCal Health is committed to providing consistent, compassionate, and local support to all CenCal Health providers and members.

CenCal Health's Pharmacy Team is comprised of Pharmacist and Pharmacy Technician staff. Our Pharmacy Team is ready to assist our provider network and membership with pharmacy-related inquires and education. 

Medi-Cal Rx: Medi-Cal Pharmacy Benefit

Effective January 1, 2022, CenCal Health's Pharmacy benefit called Medi-Cal Rx is administered through DHCS and its vendor, Magellan Medicaid Administration. Magellan provides a comprehensive suite of administrative services as directed by DHCS, which includes claims management/adjudication, prior authorization, utilization management, and customer/support. 

medi cal rx callMedi-Cal Rx is responsible for administering the following when billed by a pharmacy on a pharmacy claim: 

  • Covered Outpatient Drugs, including Physician-Administered -Drugs (PADs)
  • Medical Supplies
  • Enteral Nutritional Products

Additional information regarding Medi-Cal Rx can be found in the "Medi-Cal Rx News" tab below and directly from the DHCS Medi-Cal Rx web site

For additional assistance contact Medi-Cal Rx Customer Service at: (800) 977-2273

You may also want to visit the Medi-Cal Rx Communication page for any upcoming bulletins and news.


CenCal Health Pharmacy Services: Medical Pharmacy Management

CenCal Health and the Pharmacy Services Team will be responsible for a variety of activities including, but not limited to: oversight of clinical pharmacy adherence, Drug Utilization Review (DUR) and all utilization management associated with pharmacy services (Physician-Administered-Drug) billed on a medical and institutional claim. CenCal Health defines the utilization management of Physician-Administered-Drugs on the medical benefit as Medical Pharmacy Management. 

Additional information and education resources for CenCal Health's Medical Pharmacy Management Program can be found on our Medical Pharmacy Management page.

Medi-Cal Rx News

Medi-Cal Rx Update:

Implementation of Phase I, Wave III - Reinstatement of Prior Authorizations for 11 Drug Classes

The Department of Health Care Services (DHCS) has announced a proposed plan for reinstatement of claim edits and prior authorizations (PAs), as well as phasing out of the Transition Policy for Medi-Cal Rx. DHCS presented a three-phase plan that includes reinstatement of PAs for new start medications based upon drug classes. This approach allows providers to initiate PAs on a gradual basis while DHCS continues to grandfather prescriptions with historical claims or PAs. 

On September 16, 2022, Phase I, Wave III of the Reinstatement Plan will go-live. Providers will be required to submit PAs for new start medications in the 11 identified drug classes below. 

  • Diuretics
  • Lipotropics, including statins and omega-3 fatty acids
  • Hypoglycemics, including glucagon
  • Coronary vasodilators (nitrates and pulmonary arterial hypertension agents)
  • Cardiovascular agents, including antiarrhythmics and inotropes
  • Anticoagulants and antiplatelets
  • Niacin, Vitamin B, and Vitamin C products

New prescriptions for beneficiaries 21 years of age and under, for medications within the 11 drug classes, are excluded. Specifically, new start prescriptions for children and youth within these 11 drug classes will not be subject to PA reinstatement. 

For Medi-Cal Rx prescribers who currently fax in prior authorization (PA) requests, CoverMyMeds® allows you to submit an electronic PA (ePA) for drug/product requests to Medi-Cal Rx. 

Please visit the Medi-Cal Rx CoverMyMeds Guide for more information. 

For any questions regarding the implementation of Phase I, Wave III, please contact Medi-Cal Rx at (800) 977-2272 or CenCal Health Pharmacy Department at (805) 562-1080.   

Reinstatement of Reject Code 88 & Postponement of Reject Code 80 

What is Happening?

Effective July 22, 2022, Drug Utilization Review (DUR) claim edits will be reinstated. Specifically, claims will reject for National Council for Prescription Drug Programs (NCPDP) Reject Code 88 – Drug Utilization Review Reject Error for DUR alerts such as drug-drug interactions, high dose, early refill, etc.

Review Medi-Cal Rx billing guidelines in the NCPDP Reject Code 88 DUR Reference Guide to avoid or resolve claim rejections. 

The Department of Health Care Services (DHCS) has elected to postpone implementation of the National Council for Prescription Drug Programs (NCPDP) Reject Code 80 - Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria.

Claims submitted to Medi-Cal Rx will NOT be edited for a diagnosis code as planned to begin July 22, 2022. However, providers are reminded of their obligation to document the meeting of Code 1 restrictions and to keep that information readily available.

Please contact the Pharmacy Department with any questions at (805) 562-1080.

 

 























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Medi-Cal Rx Resources & Contract Drug List

Medi-Cal Rx Resources and Contracted Drug List (CDL)

Medi-Cal Rx Searchable Drug Lookup & Contracted Drug List

Searchable Formulary

Medi-Cal Rx Contract Drug List 

Find a Pharmacy Search Tool

Pharmacy Search

Medi-Cal Rx Support Services

The following document will provide the processing information for Medi-Cal Rx (i.e. BIN, PCN & Group) and additional payer information.

Medi-Cal Rx Support Services and Key Payer Sheet Details

 

Pharmacies requesting additional operational claims support please contact:

Medi-Cal Rx Customer Service Center at: (800) 977-2273

 

 
















































































COVID-19 Treatment Resources

 

COVID-19 Treatment Resources 

CenCal Health is dedicated to keeping our providers up to date with the most current information for the treatment of COVID-19.    The provided information gives details on the use of the pharmacy benefit and medical benefit for COVID-19 treatment. 

COVID-19 National Institutes of Health Guidelines

The following National Institutes of Health (NIH) COVID-19 Treatment Guidelines provide clinicians with evidence-based recommendations on the management of COVID-19 and are revised with the emerging, rapidly evolving COVID-19 treatment options: NIH COVID-19 Treatment Guidelines

Outpatient Treatment of COVID-19 as a Medi-Cal Rx Pharmacy Benefit

COVID-19 Oral Antiviral Treatments

  • Nirmatrelvir/Ritonavir (Paxlovid)
  • Molnupiravir (Lagevrio)

Monoclonal Antibodies for Pre-Exposure Prophylaxis of COVID-19

  • Tixagevimab packaged with Cilgavimab (Evusheld)

Monoclonal Antibodies to Treat Mild-to-Moderate COVID-19

  • Bebtelovimab

COVID-19 monoclonal antibodies and oral antiviral treatments are currently being distributed by the Department of Health and Human Services (HHS). Providers can find public locations that have received shipments of the COVID-19 monoclonal antibodies and oral antiviral treatments via the COVID-19 Therapeutics Locator (arcgis.com). For California, see Distribution and Ordering of Anti-SARS-CoV-2 Therapeutics on the California Department of Public Health website.

Remdesivir (Veklury) for Outpatient Treatment of COVID-19


The Department of Health Care Services (DHCS) will reimburse Remdesivir (Veklury) as a pharmacy benefit when dispensed for use in nonhospitalized patients in accordance with Food and Drug Administration (FDA) approval or Emergency Use Authorization (EUA).

For more information on COVID-19 treatments, including product fact sheets and patient-facing communication, visit the California Department of Public Health’s COVID-19 Treatments page.

 

Medi-Cal Rx Find a Pharmacy Search Tool


https://medi-calrx.dhcs.ca.gov/home/find-a-pharmacy/


To ensure expedited access to COVID-19 treatment users can enter their location and see Medi-Cal-Rx enrolled pharmacies or mail order options in their area. The search results can be easily sorted and filtered to find a pharmacy that specifically fits the user preferences.


CenCal Health Medical Benefit Coverage


Infused therapeutics with appropriate procedure codes can be billed to CenCal Health on a medical claim once FDA-approved (i.e., remdesivir).  Infused monoclonal antibodies are currently supplied free to providers by the federal government, CenCal Health will only reimburse the administration fees with the appropriate administration procedure code in accordance with FDA Emergency Use Agents (EUA). As infused therapeutic options become FDA-approved and supported by DHCS, NIH Treatment Guidelines, CenCal Health will be responsible for coverage if billed on a medical claim.

Treatment for COVID-19 is a dynamic space and CenCal Health will provide quarterly updates on treatments and resources.  For any questions regarding COVID-19 treatment resources please contact MediCal Rx at (800) 977-2273 or CenCal Health Pharmacy Department at (805) 562-1080.